NCLEX-RN
NCLEX RN Exam Preview Answers
1. A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?
- A. Wake the infant before beginning the examination.
- B. Examine the infant's hips before the infant wakes up.
- C. Auscultate the lungs and heart while the infant is still sleeping.
- D. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
Correct answer: C
Rationale: When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant's hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.
2. An Asian-American woman is experiencing diarrhea, which is believed to be "cold"? or "yin."? What should the nurse recognize that the woman may likely try to treat it?
- A. Foods that are "hot"? or "yang"?
- B. Readings and Eastern medicine meditations
- C. High doses of medicines believed to be "cold"?
- D. No treatment because diarrhea is an expected part of life.
Correct answer: A
Rationale: In this scenario, the Asian-American woman is believed to be experiencing diarrhea due to a "cold"? or "yin"? imbalance. According to the yin/yang theory, yang represents heat and yin represents cold. Therefore, to balance the cold nature of the diarrhea, the woman may try to treat it by consuming foods that are considered "hot"? or "yang"?. This aligns with the concept that cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. Choices B, C, and D do not align with the yin/yang theory and are not relevant to addressing the imbalance associated with the cold nature of the diarrhea.
3. During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?
- A. Fingertips
- B. Dorsal surface of the hand
- C. Ulnar portion of the hand
- D. Palmar surface of the hand
Correct answer: B
Rationale: The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.
4. When are manual hematocrits done?
- A. to monitor anemia
- B. by using a microhematocrit tube.
- C. to measure the percentage of plasma to cells.
- D. All of the above.
Correct answer: D
Rationale: Manual hematocrits are performed to monitor anemia, which involves measuring the percentage of red blood cells in the blood. The process involves collecting blood in a microhematocrit tube, then centrifuging it to separate the plasma from the cells. By measuring the ratio of plasma to cells, healthcare providers can assess the patient's hematocrit level. Therefore, all the provided options are correct as they collectively describe the purpose and procedure of manual hematocrits.
5. During an examination, the nurse notices that a female patient has a round "moon"? face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient likely has which condition?
- A. Gigantism
- B. Acromegaly
- C. Cushing syndrome
- D. Marfan syndrome
Correct answer: C
Rationale: Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and a round, plethoric face (moon face). Excessive catabolism in Cushing syndrome causes muscle wasting, weakness, thin arms and legs, reduced height, and thin, fragile skin with purple abdominal striae, bruising, and acne. Gigantism is characterized by increased height and weight and delayed sexual development, which are not present in the patient. Acromegaly results from excessive growth hormone secretion in adulthood, leading to bone overgrowth in specific areas like the face, head, hands, and feet. Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and distinct features not seen in this patient. The combination of signs described in the question aligns with the clinical presentation of Cushing syndrome.
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